IATW New Patient Paperwork

NEW PATIENT PAPERWORK

Please fill out all included paperwork to the best of your ability.
Patient Information:
First and Last name:*
DOB:*

MonthDayYear
SSN#:*
Address:*
City:*
State:*
Zip:*
Home Phone Number:
Cell Number:*
Email:*
example@example.com
Gender:*

MaleFemale
Marital Status:*

SingleMarriedDivorcedWidowedOther
Due to federal government requirements, please check the following for patient being seen. What is your Race?*

CaucasianAfrican AmericanPacific IslanderNative AmericanAlaskanAsianPrefer not to answerOther
Preferred form of contact:*

HomeWorkCellOther
May we leave a detailed message?*

YesNo
Preferred Pharmacy:
Pharmacy Phone Number:
Guarantor Information (Person financially responsible for patient)
If same as above patient, click the option below; if not, please fill out the next set of questions:*

Yes, the guarantor is also the above patient.No, I am the guarantor but not the patient.
If you are the guarantor but NOT the above patient, please fill out the questions below:
First and Last name:
DOB:

MonthDayYear
SSN:
Address:
City:
State:
Zip:
Home Phone Number:
Cell Number:
Email:
example@example.com
Gender:

MaleFemale
Relationship to patient:

SpouseParentOther
Insurance Information:
Primary:*
Contract #:*
Group #:*
Subscriber Name:*
Subscriber DOB:*

MonthDayYear
Relationship to patient:*

SelfSpouseParentOther
Secondary Insurance Information:
Contract #:
Group #:
Subscriber Name:
Subscriber DOB:

MonthDayYear
Relationship to patient:

SelfSpouseParentOther
Do you have a preferred provider?*

Steven Coppock, MDAaron Jasper, CRNPJulie Anna Wright, CRNPKelli Garrick, CRNPFirst Available/No preferred provider
Patient Employer Information:
Employer Name:
Employer phone number:
Ext:
Emergency Contact:
Name
Phone number:
Relationship to patient:
How did you hear about us? (Mark all that apply):*

Internet SearchFriend/RelativeDoctor/ReferralSocial MediaMagazine/NewspaperOther
Authorization for Release of Medical Records:

By providing this authorization, I understand the authorization is voluntary and is being done at the request of the patient. I understand that I may refuse to sign this authorization without my treatment and/or payment obligations being affected. I understand that the health information to be obtained and released may be subject to redisclosure by the recipient of the health information and no longer protected by the Federal Privacy Rules. I understand that I may revoke this authorization at any time by notifying Integrative Approaches to Wellness in writing, but if I do, it will not have any effect on uses or disclosures prior to the receipt of revocation. I understand that this authorization is valid until otherwise specified.
Name*
Relationship*
Name*
Relationship*
Assignment of Benefits & Guarantee of Account:

I acknowledge full financial responsibility for any charges incurred on my behalf as a patient, my family member who is a patient, or on behalf of the patient whom I have agreed to be the responsible party. I understand that it is my responsibility as the patient to verify my contracted benefits with my insurance carrier in reference to any services provided by Integrative Approaches to Wellness. I understand that all copays are due at the time of service. The portion which insurance does not cover is my financial responsibility. Integrative Approaches to Wellness charges a fee of $30 for returned checks. In the event of a returned check, cash or credit will be the only methods of payment accepted for your account. In the event my account is turned over to a collection agency, I agree to pay all costs, including but not limited to, collection fees and/or attorney's fees and all court costs, if any. I further agree to pay that outside agency an additional 30% on the outstanding portion of my account and hereby waive all rights of exemption under the Constitution and laws of the State of Alabama.
Signature:*

Clear
Date:*

MonthDayYear
Health History Form:
First and last name:*
DOB:*

MonthDayYear
Age:*
Why are you seeing the doctor today?*
Medical Problems:
Please list all medical problems/illnesses for which you are currently being treated:*

Surgeries/Hospitalizations:

	Surgeries/Hospitalizations	Year	Complications
1.
2.
3.

Social History: Please check all that apply:*

Employed (occupation)UnemployedDisabledWork in HomeStudentRetired
If employed, what is your occupation:
Children:*

YesNo
Children(s) Ages:
Marital Status:*

SingleMarriedDivorcedWidowedOther
Diet/ Exercise/ Lifestyle:*

DailyWeeklyRarelyNever
What type of exercise?
Are you on a special diet?*

YesNo
If so, describe:
History of substance abuse?*

YesNo
If so, describe:
Currently smoke?*

YesNo
If so, describe:
Previously a smoker?*

YesNo
If so, describe:
Drink alcohol?*

YesNo
Frequency:
Type of alcohol:
Previous Primary Care Provider?
Current Height:*
Current Weight:*
Please list ALL medications below. Failure to list all medications will result in being denied for Primary Care. If you have specialists that prescribe certain medications, please provide the Doctors name that prescribes those medications.
If you do not take any medications, please check the box below:

No Current Medications

Medications:

	Medication	Dose	How long	Prescriber Name
1.
2.
3.
4.

Allergies:*

Yes, I have allergiesNo known drug allergies

Family History:

	Allergies
1.
2.
3.

Has anyone in your immediate family been diagnosed with the following diseases? If yes, please specify: *

	Yes	No	Specify
Cancer
Heart Disease
High Blood Pressure
Diabetes
Cholesterol
Other

Review of Systems:

Are you currently having or have you had problems with the following? If yes, please describe:*

	Yes	No	Describe
Allergic/Immunologic
Cardiovascular (Heart)
Diabetes
Ear, Nose, Throat
Endocrine (Thyroid)
Eyes
Gastrointestinal
Hematologic (Bleeding)
High Blood Pressure
Integumentary (Skin)
Musculoskeletal
Neurological
Numbness/Tingling
Psychiatric
Psychological
Respiratory (Lung)
Urologic (Bladder)

Signature (Patient Signature is over the age of 13):*

Clear
Date:*

MonthDayYear
Practice Policy Acknowledgment

Please initial each line to verify you have read, understand, and agree. If you do not initial next to each line, your signature below constitutes full understanding and acknowledgment of our policies also.
Appointments: Please plan to arrive 15 minutes prior to your appointment time to complete and/or update any outstanding paperwork. It is our goal to have each patient in and out as quickly as possible without compromising the level of care each patient receives. Having all paperwork completed prior to your appointment time will assist in keeping wait times as minimal as possible.*

Clear
Missed Appointments: In the event of a no show, cancellation with less than 24 business hours prior to your scheduled appointment or leaving your appointment without yet having seen the provider, your account will be charged a $40 missed appointment fee for each occurrence. When you are not at an appointment, it takes away from another patient whom we could be assisting during that blocked time. After 3 missed appointments, we will no longer be able to schedule you for an appointment. *

Clear
Copays: We are required by law to collect copays at the time of visit, for each visit. The Health Care Financing Administration (HCFA) is the federal government agency responsible for setting policy and overseeing the Medicare and Medicaid programs. HCFA has mandated that providers of health care must collect copays and deductibles. This is enforced by the Office of the Inspector General (OIG). Providers that do not collect copays are subject to prosecution for fraudulent billing under federal law. Routine copay waiving constitutes ordinary financial fraud. Penalties include fines up to $25,000.00, five years in jail, or both. Private Insurance companies can also prosecute providers who fail to collect copays and/or deductibles.*

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Scheduled Drugs: Dr. Grelle monitors and screens ALL patients using/prescribed scheduled drugs with the Alabama Prescription Drug Monitoring Program. We do not routinely prescribe or refill requests for opioid (codeine, hydrocodone, Tramadol) or benzodiazepines (Xanax, Klonopin, Ativan). We do not carry narcotic shots in our office and encourage patients with chronic pain issues to seek treatment with specialized pain management clinics. Failure to disclose any and all prescriptions of controlled substances may result in the termination of healthcare provided at this facility.*

Clear
Test Results: Dr. Grelle prefers to discuss your lab work and/or test results with you personally at your follow-up visits. If there are any urgent and/or critical results, you will be notified promptly by Dr. Grelle or a member of her staff. You are welcome to and encouraged to receive copies of any lab work results and/or test results in order to keep a personalized health file at home. To receive records from our office, you will need to fill out a medical release form and pick records up from the office. A valid, current picture ID is required in order for records to be released to you or any authorized person listed on your release.*

Clear
In-Patient Care: Dr. Grelle's practice is an out-patient only clinic; therefore, she does not admit or manage in-patient care while in the hospital. There are a number of excellent hospitalist services and hospitals in the Tuscaloosa/Birmingham area to choose from whom provide 24-hour services. Should you need to be admitted or have an emergency after hours, please inform the ER or admitting physician that Dr. Grelle is your primary care doctor so she can follow-up and coordinate your care once you have been discharged from the hospital.*

Clear
In-Patient Care: Dr. Grelle's practice is an out-patient only clinic; therefore, she does not admit or manage in-patient care while in the hospital. There are a number of excellent hospitalist services and hospitals in the Tuscaloosa/Birmingham area to choose from whom provide 24-hour services. Should you need to be admitted or have an emergency after hours, please inform the ER or admitting physician that Dr. Grelle is your primary care doctor so she can follow-up and coordinate your care once you have been discharged from the hospital.*

Clear
Hours of Operation: Our office hours are 8:00 am to 4:30 pm, Monday through Thursday, and 8:00 am to 2:00 pm on Friday. Outside of normal office hours we defer care to the local urgent care centers or emergency rooms. If you are in need of non-urgent care during hours which we are closed please leave a voicemail on our office phone system, and we will contact you when business resumes per our callback policies.*

Clear
Print Patient's Name:*
Patient Signature:*

Clear
DOB:*

MonthDayYear
Date:*

MonthDayYear
Integrative Approaches to Wellness
Callbacks: In the event you are unable to reach one of our nurses or office staff members during normal business hours, please leave a detailed message. Our policy is to return all phone messages within 2 business days. If for some reason your message is not returned, we encourage you to try again the next business day. We also provide alternate methods of contact such as text message or e-mail.*

Clear
Consent for Treatment: I consent to necessary treatment including lab tests, x-rays, procedures, administration of medication and/or other studies that may be needed to diagnose or treat any illness that I present with.*

Clear
Guarantee of Account: I hereby guarantee the payment of my account and/or any account I have signed as the guarantor for, waive all claims of exemption under the State of Alabama, and agree to pay, if necessary, all costs of collection including attorney's fees.*

Clear
Refill Schedule: Dr. Grelle's goal is to match your prescriptions to your follow-up appointment schedule to the maximum extent practical. For this reason, we encourage you to schedule follow-up appointments before you leave from each visit and to make every effort to adhere to scheduled follow-up appointments. Following this practice will minimize the need for refill requests outside of your routine office visits. We do not prescribe antibiotics or other medications or routinely call-in refills over the phone. *

Clear
Prescription fees for medications requested outside of scheduled appointments: All requests for prescription refills made outside of office visits will be subject to a $25 fee.*

Clear
Ways to reduce unnecessary refill requests and medication errors: 1. We require office visits on a regular basis for all of our patients taking prescription medication. The interval for follow-up visits will vary depending on the medical condition being treated and type of medication you are prescribed. At a minimum, an annual visit is required in order to refill your medications and update the status of your condition. Please be sure you have enough medication to last until your next scheduled visit. 2. Before you come to each scheduled appointment, review your remaining medications, diabetic supplies, inhalers, etc. to determine if you need to request any new prescriptions at your appointment. 3. Please bring all prescription bottles or a detailed list of all your medications from all of your providers with you to each appointment. This is important to make sure that you are taking the correct medications at the correct dosages. 4. It is your responsibility to schedule a follow-up appointment before you run out of your medications. *

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Automatic Refill Systems: Some requests for refills that we receive are generated automatically from the pharmacy without the patient's knowledge. We will not respond to refill requests that are faxed from the pharmacy. If you are in need of a refill, we expect you to contact us directly and leave a detailed message on our Refill Request Voicemail. Prior authorizations faxed from your pharmacy will still be accepted.*

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Medical Form Fee: There will be a $50 fee for medical forms filled out outside of a scheduled appointment. This fee may vary depending on the length and specificity of the form and is subject to the time and depth of the form. Some forms will require a detailed appointment to assess all necessary information for completion.*

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Kindness: The staff of Integrative Approaches to Wellness will do their best to go above and beyond to meet your needs. I agree to show kindness to those working for my health and well-being. If my behavior is rude, demanding or argumentative, this may constitute a breach of the patient/physician relationship. *

Clear
Print Patient's Name:*
Signature:*

Clear
DOB:*

MonthDayYear
Date:*

MonthDayYear
HIPAA Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information (from this point on referred to as PHI) to carry out treatment, payment, or health care operations for other purposes. It also describes your rights to access and control your PHI. PHI is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related healthcare services.

Uses and Disclosures of Protected Health Information: Your PHI may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing healthcare services to you, to pay your healthcare bills, to support the operation of the physician's practice, and any other use required by law.

Treatment: We will use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party. For example: we would disclose your PHI, as necessary, to a home health agency that provides care to you or to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include collections agencies.

Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of students, licensing, and conducting or arranging for other business activities. For example: we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment.

We may use or disclose your PHI in the following situations without your authorization:
- As Required by Law
- Food & Drug Administration Requirements
- Organ Donation
- Workers' Compensation
- Public Health Issues
- Legal Proceedings
- Research
- Inmates
- Criminal Activity
- Communicable Diseases
- Law Enforcement
- Required Uses
- Health Oversight
- Coroners
- Military Activity
- Required Disclosures
- Abuse or Neglect
- Funeral Directors
- National Security
- Under the law we must make disclosures to you and when required by the Secretary of the Department of Health & Human Services to investigate or determine our compliance with the requirements of Section 164.500.
Other Permitted & Required Uses & Disclosures will be made only with your consent, authorization, or opportunity unless required by law.

You have the right to inspect & copy your PHI: Under federal law, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI.

You have the right to request a restriction of your PHI: This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restrictions to apply. Your physician is not required to agree to a restriction that you may request. If a physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. You then have the right to use another healthcare professional.

You have the right to obtain a copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.

You may have the right to have your physician amend your PHI: If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to objector withdraw as provided in this notice.

Complaints: You may complain to us or the Secretary of Health & Human Services if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of and provide individuals with this notice of our legal duties and privacy practices with respect to PHI. Your signature below is an acknowledgment that you have received this Notice of Privacy Practices.
Print Patient's Name:*
Signature:*

Clear
DOB:*

MonthDayYear
Date:*

MonthDayYear
Notice of Noncovered Services

In the event my insurance does not pay for a service, I agree to pay the noncovered amount of the test. Testing may include, but is not limited, to injections, immunizations, EKGs, lab work, in office testing, sports physicals and DOT physicals. I understand that Integrative Approaches to Wellness will make every effort to bill my insurance for these services, but under certain circumstances individual plans may not cover all services. Fees are subject to change at any time, but to the best of our knowledge, current fees are as listed below:
Print Patient's Name:*
Signature:*

Clear
DOB:*

MonthDayYear
Date:*

MonthDayYear
Agreement on Controlled Substance Therapy
The purpose of this Agreement is to create an understanding regarding controlled substances (a type of medication that is regulated by states and the Federal government) that may benefit your chronic condition(s). Our goal is not only to treat you safely with these potent medications, but to also prevent abuse of or addiction to these medications. Medications such as pain medication (opiates, gabapentin, etc.), sedatives (benzodiazepines, sleep medication, etc.), and stimulants (amphetamines) that may be useful in managing chronic conditions, can be problematic in several ways.

Although these medications may be prescribed with the goal of improving your functionality, their medical use is also associated with the risk of serious adverse effects including development of an addiction disorder or a relapse in a person with a prior addiction history. The goal is to have you take the lowest possible dose of medication that is reasonably effective in managing your pain and improving your function, and when possible, have it tapered and eventually discontinued, while at the same time monitoring and managing these potential risks.

Because these medications have the potential for abuse or diversion (i.e. sharing, trading or selling to ANYONE other than whose name is on the prescription), strict accountability is necessary for both medical safety and legal reasons. Therefore, the following policies are agreed to by you, the patient, to help keep you safe and to provide you with good care.

Please initial next to each item to indicate your understanding and agreement:
I agree to only take controlled substances prescribed by the provider that I see at Integrative Approaches to Wellness, or, during his or her absence, by the covering provider.*

Clear
I will not take controlled substances written by another provider or specialist unless I have notified my provider PRIOR to filling the prescription. *

Clear
I will obtain all controlled substances from the same pharmacy, listed below. Should the need arise to change pharmacies, I will inform the office staff. *

Clear
I will inform the office of any new medications or medical conditions and any of the adverse effects I experience from any of the medications that I take. *

Clear
I agree to give the prescribing provider permission to discuss all diagnostic and treatment details with dispensing pharmacist or other professionals who provide my health care for purposes of maintaining accountability and coordinating my care. *

Clear
I agree not to share, sell or otherwise permit others to have access to these medications. I will take all medications exactly as prescribed, and I will not change my dose without first discussing changes with my provider. *

Clear
I understand that I am not to stop these medications abruptly or without consulting the prescribing provider, as an abstinence/withdrawal syndrome may develop. *

Clear
I agree that my urine may be tested for controlled substances before initiation of therapy and that random urine follow up testing will be done. I will cooperate in such testing, and I agree that the presence of unauthorized substances, illicit substances or absence of prescribed medications may prompt referral for assessment for addictive disorder and possible tapering and discontinuation of the controlled substance immediately or in the future. *

Clear
I will bring original containers of medication to each office visit. *

Clear
I agree that medications will not be replaced if the are lost by any means. If my medication has been stolen, I will complete a police report regarding the theft and present that report to the prescribing physician, and I understand that an exception may be made at the discretion of my treating physician. *

Clear
I agree that early refills will not be given, I agree that that prescription renewals are continent on keeping scheduled appointments. I will not phone for prescriptions after hours or on weekends. *

Clear
I agree that, if the responsible legal authorities have questions concerning my treatment, as might occur, for example, If I was obtaining medications at several pharmacies, all confidentiality is waived, these authorities may be given full access to my records of controlled substances administration. *

Clear
I agree that failure to adhere to these policies may result in tapering and cessation of therapy with controlled substances prescribing by this physician or referral for further specialty assessment.*

Clear
I recognize that any medical treatment is a trial, and that continued prescription is contingent on evidence of benefit and improved functionality. *

Clear
I acknowledge that the risks (listed separately) and potential benefits of therapy with controlled substances have been explained to me and that I have had the opportunity to ask any questions that I may have. I understand and agree that failure to adhere to these policies will be considered noncompliance and may result in cessation of opioid prescribing by my provider and possible dismissal from this clinic. *

Clear
Patient Name:*

First NameLast Name
Patient DOB:*

MonthDayYear
Date
Patient/Guardian Signature:*

Clear
Date:

MonthDayYear
Date
Controlled Substance Risks:
Should be Empty:

NEW PATIENT PAPERWORK

Patient Information:

Guarantor Information (Person financially responsible for patient)

If you are the guarantor but NOT the above patient, please fill out the questions below:

Insurance Information:

Secondary Insurance Information:

Patient Employer Information:

Emergency Contact:

Authorization for Release of Medical Records:

Health History Form:

Medical Problems:

Please list ALL medications below. Failure to list all medications will result in being denied for Primary Care. If you have specialists that prescribe certain medications, please provide the Doctors name that prescribes those medications.

Family History:

Review of Systems:

Practice Policy Acknowledgment

Integrative Approaches to Wellness

HIPAA Notice of Privacy Practices

Notice of Noncovered Services

Agreement on Controlled Substance Therapy